“Covering provider”: an effort to streamline clinical communication chaos

Abstract Objective This report describes a root cause analysis of incorrect provider assignments and a standardized workflow developed to improve the clarity and accuracy of provider assignments. Materials and Methods A multidisciplinary working group involving housestaff was assembled. Key drivers were identified using value stream mapping and fishbone analysis. A report was developed to allow for the analysis of correct provider assignments. A standardized workflow was created and piloted with a single service line. Pre- and post-pilot surveys were administered to nursing staff and participating housestaff on the unit. Results Four key drivers were identified. A standardized workflow was created with an exclusive treatment team role in Epic held by a single provider at any given time, with a corresponding patient list column displaying provider information for each patient. Pre- and post-survey responses report decreased confusion, decreased provider identification errors, and increased user satisfaction among RNs and residents with sustained uptake over time. Conclusion This work demonstrates structured root cause analysis, notably engaging housestaff, to develop a standardized workflow for an understudied and growing problem. The development of tools and strategies to address the widespread burdens resulting from clinical communication failures is needed.

-Method and medium to contact attending -Not 100% on Voalte -Not 100% on SmartPage -Usually ED will page the resident on the service who has to figure this out B. Pt direct admit -can arrive on floor with only Attending assigned C."Qualifying ADT message" for time-based assignment do not update Voalte care team automatically -Manual assignments qualify, and update care team D/F Needs to be a manual assignment, not always assigned, different titles on different services E/I.Primary resident not always assigned, primary resident may not be expected to write orders, may be off G/H.Cross-cover provider assignments not consistently made F. Consulting Provider not assigned to patient -Smart Page for Consulting Service does not always display named user -Consulting team usually does not assign themselves to patient, just "log on" to Voalte and are searchable -Pt tx to OR pool room (off-unit) -No pt integration with Epic Optime; no MD assignment updates made -Pt tx to Imaging will stay in same pt room/bed in Epic/Voalte L. Crosscover can add end time to Epic assignment which makes unassignment automatic, not consistently done.Sometimes manual and crosscover remains assigned H/I/L/M/N: No culture of unassigning ordering providers/residents at end of shift or on days off from Epic J. Providers forget to log off on Voalte when they leave so they appear to still be assigned even if at home K/O.Calling to cover pagers is a manual and time consuming process.Introduces delays in assignment to patients because cross cover waits to have collected a few pages prior to calling.
-Person covering pager calls operator to assign to specific pagers for certain period of Consultants don't want to add themselves due to excessive messages better served to primary team.2.In the Unit: If consult placed in ED; provider from ED is still assigned when patient arrives to the floor.
-Often caught in large group messages that aren't pertinent and difficult to take off easily -Difficult to get patient name in subject line for 1:1 message -First and second call system is not established 3.Direct Admit: Difficult for consultant team to know who is responsible for patient to discuss plan 4. Unclear often who is primary especially with multiple surgical sub-specialties.5. Cross cover provider assignments not consistently made.Takes a lot of time to add yourself as a cross cover, not easy to highlight everyone as a cross cover, people don't always do that.
-Not easy to take yourself off a patient 6. CDU APPs and attendings often are not assigned, and there are often acute issues with these patients.

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If pager doesn't get covered, often found out because person holding pager gets can we get data to support this?) A. Primary team members not consistently unassigned B. On transfer, teams will intentionally want to remain assigned as primary team in order to follow patient (Onc APP service Med 9/11).Minor issue as patient is in ICU based on room number and people know who to contact C. All messages w/ ICU team phone go to single person holding phone even though multiple providers are on the team -If MICU provider has personally assigned, first contact manually assigned which offers opportunity to miss it B. Prior team members often remain assigned C-F: Can lead to situation where prior first contact, new first contact, and cross cover are all simultaneously assigned -A.Process for whether TT alone, TT + first contact is assigned varies depending on new primary service -All prior slide pain points apply Points: (Where can we get data to support this?) 1. ED consult -ED Team not always assigned -unclear during shift changes -originally page is via spok and requires call back (time consuming) -Contacting attending to accept pt -most services contact own service attendings via cell -not actionable -After completion of consult resident defers care to intern for floor team -not always signed out well 2. Pt direct admit -can arrive on floor with only Attending assigned -ALLOW FOR AUTOMATIC ADDITION OF TEAM (always the same) -Ideally automatic addition of resident (would require resident assigned to treatment team in epic 3. Old providers staying on chart after transfer Allow for reset of assignments on transfers / can manually remove other providers -4.See OR pain points slide -not viable in OR as privacy -nurse must open personal phone, connection issues, OR staff not assigned -possible fix point would be nurse to nurse communication when scrubbed -5."Qualifing ADT message" for time-based assignment do not update Voalte care team automatically -Manual assignments qualify, and update care team --many night float default to spok, home call if difficult to wake up to voalte notifications.-6.Cross-cover provider assignments not consistently made -Consulting Provider not assigned to TT, only service -Smart Page for Consulting Service does not always display named user -Pt tx to OR pool room (off-unit) -No pt integration with Epic Optime; no MD assignment updates made -Pt tx to Imaging will stay in same pt room/bed in Epic/Voalte 7. Pt in PACU -PACU staff currently only using Spok -which is covered by intern who generally not aware of surgical course 8. Same theme.ICU team generally does not assign directly under patient (uses triage or bat phone) the ED: Difficulty identifying the person assigned to the patient, for f/u of recommendations and plan of care.
consultant team to know who is responsible for patient to discuss plan.-Twosystems to communicate and to consult providers: Voalte and Pager: Inconsistency of providers signing to Voalte.-Highpriority messages underutilized.